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Table 3 Proximal objectives and strategies for programme delivery

From: Synthesising practice guidelines for the development of community-based exercise programmes after stroke

Proximal objectives & recommended strategies

Ev

n

Au

Ca1

Ca2

Ca3

Ca4

Ca5

Eu

Ne

NZ

SA

Si

UK1

UK2

UK3

US1

US2

US3

US4

US5

[41]

[37]

[42]

[38]

[43]

[1]

[44]

[3]

[48]

[36]

[49]

[45]

[47]

[35]

[39]

[40]

[34]

[2]

[46]

8

Personalise programme to individual

 

5

             

X

X

X

X

X

 
 

a. Multidimensional pre-assessment conducted by healthcare professional addressing health status, cautions, contraindications and risks

2

7

  

X

     

X

    

X

X

X

X

X

 
 

b. Pre-programme assessment by trainers to enable individualisation of programme

3

3

   

X

         

X

X

    
 

c. Adapt programme content to personal situation and goals

2

8

X

 

X

     

X

  

X

 

X

X

 

X

X

 
 

d. Evaluate programme effects on individual, including satisfaction, functional gains, personal goals, resource use, energy levels

3

3

             

X

X

  

X

 
 

e. Supplement group classes with individual sessions

3

1

             

X

     
 

f. Sub-divide group classes according to disability levels

3

1

             

X

     
 

g. In group classes, conduct functional strengthening exercises together to allow individual monitoring

3

2

             

X

X

    
 

h. Intensity should be adjusted to the individual

3

4

  

X

        

X

 

X

 

X

   
 

i. Pre-programme ECG assessment for exercise level

3

1

               

X

   
 

j. If maximal heart-rate is unknown, use low intensity but increase training frequency/duration

3

3

  

X

           

X

X

   
 

k. Shorter, more frequent exercise for frail or deconditioned

3

1

  

X

                
 

l. Use of memory aids where necessary

3

3

        

X

  

X

 

X

     

9

Ensure dosage is sufficient to establish and maintain benefits

 

2

      

X

 

X

          
 

a. At least 3 days/week physical exercise

1

1

             

X

     
 

b. 20-30 minutes daily moderate intensity physical exercise

3

2

          

X

X

       
 

c. Progression: increase load / required effort over time

1

5

X

 

X

        

X

 

X

   

X

 
 

d. Aerobic exercise 20–60 minutes, 3–7 days/week; continuous or accumulated

2

2

 

X

             

X

   
 

e. Cardiovascular endurance should be large proportion of activity

3

1

               

X

   
 

f. Strengthening exercises: 4–10 types, 2–3 days/week

3

3

  

X

          

X

 

X

   
 

g. Flexibility exercises: 2–3 days/week

3

2

  

X

            

X

   
 

h. Coordination & balance exercises: 2–3 days/week

3

2

  

X

            

X

   
 

i. Upper limb exercises 1 hour, 6 days/week

3

1

 

X

                 
 

j. Warm-up: 15–20 minutes including range of movement and large muscle group activity

2

2

             

X

X

    
 

k. Aerobic warm-up and cool-down, 3–5 minutes at lower intensity

2

2

  

X

          

X

     
 

l. Aerobic: up to 10 exercises alternating cardiovascular & local muscle endurance

3

2

             

X

X

    
 

m. Include home exercises to increase dose

3

4

  

X

X

    

X

    

X

     

10

Structure programme to facilitate ongoing regular physical exercise

 

4

X

 

X

          

X

   

X

 
 

a. Pre-programme contact to discuss any programme barriers

3

3

  

X

          

X

 

X

   
 

b. Peer/volunteer to accompany to first one or two sessions

3

1

             

X

     
 

c. Minimal use of equipment to facilitate home practice

3

1

             

X

     
 

d. Promote family / carer involvement

1

10

X

 

X

X

    

X

X

 

X

  

X

X

X

X

 
 

e. Use peer mentoring

2

2

        

X

    

X

     
 

f. Use group format for social support

3

1

             

X

     
 

g. Provide opportunities to socialise before and after training

3

2

             

X

X

    
 

h. Use of mixed media including internet-based and tele-training

2

4

        

X

     

X

  

X

X

 

i. Locate at home or centre according to personal circumstances / preferences

1

5

X

  

X

 

X

        

X

  

X

 
 

j. Locate in own residential environment

1

3

    

X

  

X

 

X

         
 

k. Provision of transport where necessary, or locate near good public transport links

3

5

X

 

X

        

X

 

X

X

    
 

l. Convenient time

3

1

  

X

                
 

m. Ongoing programme provision

3

2

  

X

          

X

     
 

n. Sign-post to other relevant services / facilities

3

4

X

       

X

  

X

     

X

 

11

Ensure adequate staffing numbers to provide safe and effective training

 

2

      

X

      

X

     
 

a. Instructor: participant ratio: 1:3 to 1:5

3

1

  

X

                
 

b. Instructor: participant ratio: up to 1:8 depending on mix & time since started exercising

3

2

             

X

X

    
 

c. Supernumerary volunteers or trainees to take part in sessions

3

1

             

X

     

12

Ensure staff are adequately trained for client group

 

1

             

X

     
 

a. Delivered by instructors with knowledge and training in exercise and stroke

3

3

  

X

         

X

X

     
 

b. Provide in-service training to instructors

3

1

             

X

     
 

c. Ensure stroke-awareness training of frontline staff in course venue

3

1

             

X

     

13

Integrate programme into stroke pathway

 

3

    

X

        

X

  

X

  
 

a. Develop partnership agreements between stakeholders

3

1

             

X

     
 

b. Referral by healthcare practitioner using clear eligibility criteria

3

2

  

X

          

X

     
 

c. Encourage referring practitioner to visit programme

3

1

             

X

     
 

d. Established procedures for transferring responsibilities from referrers to trainers

3

2

             

X

X

    
 

e. Ongoing communication with (and feedback to) other stakeholders including healthcare professionals, service commissioners, local stroke networks

3

2

             

X

X

    
 

f. Referral for other treatments where appropriate

3

2

             

X

X

    

14

Ensure adequate programme governance

 

1

             

X

     
 

a. Oversight by management group

3

1

             

X

     
 

b. Plan for programme evaluation

3

2

  

X

          

X

     
 

c. Use procedures for recording and reporting adverse events

3

2

  

X

          

X

     
 

d. Follow data protection procedures

3

1

             

X

     
 

e. Obtain and check ongoing consent

3

2

  

X

          

X

     
  1. Ev = highest level of evidence presented for strategy.
  2. n = number of guidelines explicitly including objective or strategy.
  3. Au = Australia; Ca = Canada; Eu = Europe; Ne = Netherlands, NZ = New Zealand; SA = South Africa; Si = Singapore.
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